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EFC 2019 Prescription Drug and Medicine Authorization

MONDAY, July 8 - FRIDAY, July 12 2019

Senior High & Leadership arrives July 7

Camp Courage, Maple Lake, Minnesota

First Name

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Last Name

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Parish*

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Name of Prescription/Medicine #1

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Prescribing Doctor

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Dosage Amount

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Times to be given

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Duration ofr Prescription

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Name of Prescription/Medicine #2

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Prescribing Doctor

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Dosage Amount

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Times to be given

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Duration of Prescription

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Name of Prescription/Medicine #3

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Prescribing Doctor

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Dosage Amount

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Times to be given

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Duration of Prescription

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Name of Prescription/Medicine #4

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Prescribing Doctor

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Dosage Amount

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Times to be given

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Duration of Prescription

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I hereby authorize Extreme Faith Camp to dispense medicine to my child as directed. I acknowledge that by clicking "Yes" I am indicating my intent to sign this document. *

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Yes

Name of Parent/Guardian filling out and signing document.*

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